Posted by: michelle @ books my kids read | May 28, 2009

medical musings

With my husband finishing his residency this year and having gone through all of the interview process and trying to find where to go into private practice, I have had a lot of conversations about the state of the medical industry. The other day, my husband gave me a fascinating article from the New Yorker on “The Cost Conundrum.” I should preface this by saying that the author, Atul Gawande, is one of my favorites. I read his book Better two years ago and it was simply amazing.

So anyway, this article is about the fact the the price we pay for medicine isn’t necessarily getting us better care. He looks at a small town in Texas that is one of the most expensive health-care markets in the country based on Medicare spending. Then he compares this with the likes of the Mayo clinic which is in one of the least expensive markets. What it seems to come down to, which doesn’t surprise me in the slightest since I understand the medical world so much more than I used to, is that the doctors in this small Texas town (and lots of other places) are running tests they don’t need to do, encouraging patients to do procedures they don’t necessarily need, and in general are finding ways to line their pockets.

So then the interesting part is that the communities that seem to have the less expensive systems are the ones where the doctors aren’t getting money based on what kind of insurance their patient has and/or how many big procedures they can do. The Mayo Clinic is salaried. A community in Colorado decided that they would get “a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients.” And they also have started their own peer-review meetings to share charts and root out any problems that might be occurring. In short, they are working as a team.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

So back when we were looking at where to apply to for private practice, I kept going back to the notion of Kaiser. I grew up in the Kaiser system and while it is far from perfect, it is a really excellent system. My husband kept balking at the idea – he didn’t want to work in a system where the doctors didn’t make the decisions about how to treat their patients. Or so he said. That is how many HMOs work, but not Kaiser. I knew his father wasn’t a fan of the system, but I didn’t know all of the details, just that there was some issue when Kaiser tried to come into North Carolina. So finally it comes out that his biggest beef with Kaiser is that they are salaried versus paid by how much they bring in. My jaw dropped to the floor.

Way before reading this artical by Gawande, I understood that this method made more sense. There is more respect for the patient as a person if you aren’t thinking about how you can word their claim to get the most cash. The patient care is better and often they are practicing preventative medicine instead of just trying to fix a problem once it has happened. As a company, they actually make more money when the don’t perform the big surgeries but rather find ways to enable their patients to stay well.

When I was in college I had a serious headache problem. Most doctors, even within the Kaiser system (I said it wasn’t perfect) tried to give me various pain medications to make the problem go away. Then finally someone referred be to the headache clinic. A clinic! They were my saviours. They tried to find ways to make the headaches not happen. Sometimes, they just wanted me to come in to talk and check up on my progress. I would not have graduated without the support of some of the nurses there.

There is something wrong with our insurance system and the result is that we are creating a world of doctors who aren’t in it for the patients, they are in it for the money. I know I’m letting my uber-liberal progressive leftist god knows what beliefs shine through here, but the health of this country shouldn’t be big business.  I applaud Gawande for his article. He hits the nail on the head:

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.


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